on hating lawyers

As if I needed another reason to hate the malpractice system: It is becoming clear that the reason no one will let third – or fourth – year students do anything valuable is because of malpractice. Not because spending these two years doing nothing somehow enhances our capability to transition in a quantum-leap fashion from bystander to doctor-in-charge; and not because we’re inherently less capable of technical learning than an intern; but because the insurance covers actions of an MD, and of an RN, but not of an MS3. People tell me that it used to be different 20 years ago, and indeed my own expectations – both of abuse and of learning opportunities – are based on books from “back then.” But now our dear friends the lawyers, with the patient’s best interests at heart, of course, have caused us to be forced to waste more time doing nothing and learning (relatively) nothing. If we started learning technical skills now, we would be that much better at them by the time we became independent doctors. As it is, procedural learning is being backloaded into residency; at the same time that residency hours are being cut down. So we have more to learn, and less time to do it in. (Not that I any longer object to 80hr weeks, but there’s still a problem.)

<grinding teeth in frustration> I feel like making really extravagant statements, going around begging the senior residents and attendings to let me do things, offering bribes of homemade cookies or something. But I can’t make myself do it. For one thing, I doubt that these people will be moved by tearful females; wrong impression to make. For another, there’s a limit to how far I can humiliate myself, asking again and again only to be turned down every time. I was talking to a fourth year student, doing an anesthesiology rotation, the avowed point of which is to teach the student how to intubate patients. He’s intubated three in the last week, at a hospital where another case starts every hour all day long, because the anesthesiologists and CRNAs won’t let him near the patients. He’s happily spending his time in the library, overjoyed at having found a surgical rotation which requires no work. But I can see this going on for all of my fourth year, and I can’t bear the prospect.

I mean, I agree that I’m an absolute idiot when it comes to holding those long instruments and getting the needle to go along a designated curved track. But you could let me try, once or twice, to tie off a pedicle; sooner or later I’d get it right. I promise, I really will not cut any arteries (major ones, at least); I promise, I would stay far away from the bladder; I promise, I would always cut less rather than more, and you could fix it. Maybe a knot; I know how to tie knots; I’ll tie hundreds on my clipboard to demonstrate. One knot isn’t going to kill the patient, and the lawyers would never know. . . Crying at surgeons really is not going to do me any good, and I’m too upset to do much else. Bother bother bother. I’m paying $80+ per day to not learn this? If I were just as a courtesy being allowed to stand in the room, okay maybe; but I’m paying money, good money, to not do anything. Bother bother bother.

(*Re-reading this as I’m moving my archives at the end of fourth year, having matched in surgery, I just want to specify that I am horrified at my wild ideas at this point, and have sincerely repented of all ambitions to touch anything more than the attending says to, and am quite prepared to spend the next year not doing anything. It’s too dangerous, and there’s too much to learn. Just clamp an artery, indeed; Alice, you were crazy.*)

But to be honest, I have to admit that this is a hunger that will never be satisfied short of full operating privileges, and hopefully even then I’ll still be wanting to learn new procedures. Yesterday morning I assisted a very pregnant resident in a complex vaginal case. Everyone was in terror of her going into labor in the OR (she quite logically declined any offers to sit down or relax, since she’s at term), so the attending had me retracting, and juggling the clamps, even more than she did. Not that I was doing much myself, but I was definitely being useful, and I was doing more than the resident was. So that was extremely nice. Especially after the second year resident had scoffed at my proposal to let the two students do more while the intern’s away, and I didn’t have the nerve to try again on the chief. And I have been just grabbing the suture scissors and cutting sutures at the slightest opportunity, not letting myself let go of them unless the attending downright takes them away; which he would do because I’m such a horrible suture cutter. They keep saying “1 cm long,” but I don’t know how long a centimeter is anyhow – try inches instead – and deep inside an abdominal or vaginal cavity I can’t judge depth that well anyhow. But maybe by the end of surgery rotation I will be able to cut sutures to everyone’s satisfaction, and they’ll maybe let me place a hemostat to hold a little bit of tissue. . .

And then, it turns out that I was on call yesterday, which I wasn’t planning on. But that surprise seems to have shaken whatever it is that makes me not have any action on call. Three minutes into sign-out at 5pm, the nurses called for a doctor in one of the rooms. The intern and I ran, and he’s better at getting dressed fast than I am, so he got the baby. Fifteen minutes later, while we were still working on the placenta and checking for lacerations, the intern who was going off duty was called to another delivery down the hall. That left us with five patients in active labor. We ran to get dinner, and shortly after we got back, another lady was ready. This time I got dressed fast enough (okay, so I did pick up the intern’s size 8 1/2 gloves instead of my own 7s) and delivered the baby. Not that I was really doing anything except holding the head, and moving the shoulders down and then up; and then I nearly dropped the baby, it was so slippery. I just barely managed to hold it while the intern clamped the cord, and then had to push it into his arms before it slid out of mine. He told me afterwards that the problem was that I was trying to hold the baby, instead of just trying to maintain a grip on any piece at all. Apparently it’s ok to hold them upside down.

For a couple of hours then we checked on the other four patients. It was really awful. They were almost all primiparas, mostly being induced for hypertension, and all progressing at about the same astonishingly fast rate for primips being induced. The senior residents had the hardest time believing our reports: “You say the one in room 2 is 4 cm dilated and 70% effaced? I though that was room 6.” “Well, yes, they’re both 4 and 70.” “Oh, but the fetal station – what was that? It was 0 in room 2, right?” “Yes, and also in rooms 6,9, and 11. . .” And the blood pressures, and the contractions, and the fetal heart rates. . .

The next one to have her baby had asked the third year resident, upon walking in followed by two students, whether she was a “real” doctor. The resident looks as young as me. She cheerfully explained that yes, she was a doctor. But I got the definite impression that she didn’t like students; which is her right. So I was willing to let the resident deliver that baby, but the residents generally are very protective of the few things students are allowed to do, and don’t take kindly to patients making remarks about real doctors vs. students. So I delivered that baby, with a good deal of assistance because it had stuck its hand right up under its chin, which had been causing decels, and was very confusing when checking for a nuchal cord, plus making it hard for the shoulders to get out. When the resident decided to explain some aspect of delivery to me right during the lady’s final contractions (which I did already know, it’s ok), the patient muttered something about “why you have to learn on me.” I felt really bad for doing that to her, so I kept my comforting-and-informative conversation at top notch afterwards while delivering the placenta and cleaning her up, and then she said thank you. So that turned into a satisfying interaction. The residents so often don’t talk to the patients much about what’s happening, and when they do they use lots of medical lingo, and think that just because the patient didn’t ask means they understood. I try to do a sort of rear-guard action when I can, repeating their pronouncements (after they’ve gone on to work on the charting) in more colloquial language, and trying to explain why we’re doing things. It feels like a lot of the time the patients are supposed to trust blindly that our incomprehensible activities will have a desirable effect; I think it’s comforting to the patient even to say things like, this procedure helps us keep a closer eye on the baby; or, this will help the baby be born sooner; things that they obviously would agree with.

Then, I ran over the ER behind the chief, to see a case of evisceration: The sutures had torn right through, and the omentum was coming out, plus bowel too when they opened her in the OR. All the OB people were slightly flustered, the attending repeating that she had never seen such a case even in residency. So they called the general surgeons to give a second opinion, and advice on what to do about. They were polite, for being woken up at midnight, but you could see where the legend of OB/GYNs as incompetent surgeons outside a very small purview comes from. I took a chance on missing the other deliveries, which all seemed to be imminent, to watch that, so I won’t need to call the surgeons if it happens to me.

Another baby was delivered around 3am, but I was in the room with the other girl who was complete and pushing. She was only fifteen, and this her first baby. At first her mother had been in the room, holding her hand and being very calm through her daughter’s hysterics. But as the night wore on and the girl became more and more uncomfortable, the mother broke down and had to leave the room, so the patient’s grandmother and aunt were helping her. And then whenever we wanted to do anything we had to hunt up the mother to give consent. By 3am she was complete, and the nurse was trying to get her to push, but she was having a bad time of it, in too much pain to push effectively (I don’t know what had happened to the epidural), and too emotional to benefit from coaching. The nurse and I worked with her for more than two hours, with the residents and attending walking in and out, looking at the strip, which was showing wild early decels (right with contractions) which might or might not have been turning into lates (lasting after the contraction. Finally, at 5:30, they tried to use a vacuum, because she was still, after two hours, not even crowning. The vacuum didn’t help, so they decided to go for a Csection, and I had to leave for rounds. That was so sad; a fifteen year old having a Csection? At least her family seemed more coherent and tightly knit than a lot of the black families here. I was especially impressed by the mother’s partner (I missed whether they’re married or not), who said that he was only the girl’s stepfather, but he planned on being the real father to the baby.

So, a fantastic night, except that nobody slept a wink, and that made 24+ hours continuously on my feet. I had much ado not to fall asleep onto the sterile field this morning in surgery. I escaped as soon as possible. The dear GYN chief, the one who ignores students, assigned me Monday morning a ten-minute presentation on “abnormal uterine bleeding,” due tomorrow morning. . .